Covid-19 poses two dire threats to the United States: the potential death of 200,000 to 1.7 million Americans, according to a set of Centers for Disease Control and Prevention scenarios that were first reported by The New York Times; and the devastation of the $22 trillion annual economy.
To complicate matters, most experts agree it will likely be 12-18 months until a vaccine and proven antiviral drugs are available.
Protecting the health of as many people as possible by shutting down ordinary life seems completely justifiable, but that necessarily inflicts damage to the economy. This is truly a dilemma.
At its fulcrum is the length of time needed for social distancing, home quarantine, closures of schools, universities and businesses, and case isolation to “flatten the curve” of viral spread. The conundrum is that limits on in-person interactions will be required to protect the population, but these must be relaxed, if not lifted, as soon as possible so the economy can be jump-started.
In short, what’s needed are creative approaches to protecting those who are vulnerable, while keeping our society functioning and economy running. One possible solution might be the improvement of two key tasks: diagnostics and the grouping of populations.
We have already seen the importance of diagnostics. Without testing, there is no way to accurately know who has been infected, has recovered or remains at risk. Test kit shortages led to rationing of diagnostics, as well as persistence of uncertainties about the demographics, characteristics, impact, risk and threat of the disease.
Such accurate, reliable information is crucial to public health, and if early test kit problems and now medical staff, space and equipment shortages weren’t an issue, we would be testing all who need or desire it.
The speed of producing test results is just as important as the availability and reliability of the tests. The diagnostic tests currently being used in the US take too long for results to be available, which further complicates intervention and treatment efforts. Current testing using reverse transcription polymerase chain reaction (RT-PCR) techniques identifies viral sequences of RNA to determine if an individual has an active infection. In other words, it identifies those individuals who are potentially infectious and need to be isolated. Unfortunately, patients must usually wait several days until results are available.
What is needed are real time, point-of-care diagnostics that give patients and clinicians results while they wait. These methods would need to be inexpensive, readily available and easy to use. Such rapid RT-PCR testing will one day be offered but is not currently available in the way that we need — in the doctor’s office, while the patient waits.
Testing would also need to be expanded to identify who has already been infected. This would require serological diagnostics that identify the presence of antibodies to Covid-19.
We would also need to categorize individuals into different groups and consider distinct approaches to care and engagement for each. Currently, infected patients must strictly adhere to social distancing, home quarantine, and case isolation. Some of these patients may still be recovering and recuperating from the effects of the disease.
Those most vulnerable — including individuals in their 60s and older and all patients with preexisting conditions such as cardiovascular disease, diabetes, chronic respiratory disease, hypertension, cancer and those in intensive care units — must be most rigorously protected.
But there is also a third group: those who have been exposed to or infected with the coronavirus and recovered — who are likely now immune to infection. While anecdotes about suspected reinfection cases have been reported, it’s worth noting that a newly published experiment on rhesus macaques found that reinfection wasn’t possible. Once verification of this macaques study has been completed, we can assume reinfection is not a risk for humans.
Some in this immune group may have been exposed and never developed signs and symptoms. Others may have been infected and fully recovered. Of note, this group includes people who have recovered from the infections and are still shedding “viral debris,” which is not contagious, and therefore these people are likely no longer at risk of spreading infection to others.
But this is where it becomes interesting. There could currently be an unidentified group that may have had only mild symptoms, was never tested and who are now immune. This group could potentially be very large. For example, early in the pandemic one US state governor indicated that despite the official counts of five known cases, public health experts were estimating 100,000 actual cases within the state.
If accurately identified, public health officials could decide that such people could be released from social distancing measures and get back to work. If further studies suggest that reinfection is not possible, a broad serological testing campaign solution could help with the public health – economic stability dilemma. Tests are being developed and could be prioritized to serve as a useful tool for allowing those with Covid-19 immunity to return to the workforce.
Risk-based approaches will need to be developed for those who have not been infected so as to minimize chances that they will catch the disease. For those with preexisting conditions, some form of social distancing likely will be required until safe and effective antiviral therapeutics or a vaccine become available.
Enhanced diagnostics using rapid, readily available testing, and serological methods to determine who has immunity, combined with continued social distancing for protecting the vulnerable, might be a way forward. If reinfection isn’t possible, then employing these measures could avoid both further loss of life and economic devastation, and in this way address each of the horns of the public health-economic crisis dilemma to blunt the penetrating effects of both. All of this will require a very big investment of money and organization that is far beyond what the US has been able to accomplish so far, but it doesn’t mean that it’s impossible.
Editor’s note: Daniel M. Gerstein of the RAND Corporation formerly served as the acting undersecretary and deputy undersecretary in the Science and Technology Directorate of the Department of Homeland Security from 2011-2014. Gerstein’s latest book is “The Story of Technology: How We Got Here and What the Future Holds,” published by Prometheus Books. James Giordano, PhD, is a professor in the Departments of Neurology and Biochemistry, and a Senior Scholar of the Pellegrino Center for Clinical Bioethics at Georgetown University Medical Center. The opinions expressed in this commentary are those of the authors.
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